A nurse in a clinic is collecting data from an adolescent who has type 1 diabetes mellitus.Which of the following findings is the priority for the nurse to report?

Client's current blood glucose is 220 mg/dL

Client is exhibiting Kussmaul respirations

Client reports vomiting once that day

Client reports frequent urination

Answer and Explanation

The Correct Answer is B

Choice A reason:

A blood glucose level of 220 mg/dL is elevated and should be addressed, but it may not be an immediate priority compared to the presence of Kussmaul respirations.

Choice B reason.

Correct. Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), a severe complication of diabetes. This requires immediate attention and intervention.

Choice C reason:

Vomiting is a concerning symptom, but it may not be as immediately life-threatening as Kussmaul respirations.

Choice D reason:

Frequent urination is a common symptom of diabetes, but it may not require immediate intervention unless it is accompanied by other severe symptoms.

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Correct Answer is C

Explanation

Choice A reason:

A maculopapular rash may be an allergic reaction to the antibiotic. While this should be reported, wheezing is a more urgent concern.

Choice B reason:

A headache may be a side effect of the antibiotic, but it is not as urgent as wheezing.

Choice C reason:

Wheezing can indicate a potential serious allergic reaction or anaphylaxis to the antibiotic. This is the priority finding to report to the provider.

Choice D reason:

An increased pulse may be a side effect of the antibiotic, but it is not as urgent as wheezing.

A. "You should place a folded blanket to pad the back of the infant's head." B. "You should position the car seat at a 30-degree angle." C. "You should use a car seat with a four-point harness." D. "You should place the retainer clip at the level of the infant's armpits."

Correct Answer is B

Explanation

Choice A reason:

Placing a folded blanket to pad the back of the infant's head is not recommended, as it can interfere with the proper fit of the car seat harness and potentially be a safety hazard.

Choice B reason:

This statement is correct. Infant car seats should be positioned at a 30-degree angle to provide optimal support for the infant's head and neck, as well as to prevent airway obstruction.

Choice C reason:

While car seats with a four-point harness do exist, a standard infant car seat typically has a five- point harness system.

Choice D reason:

The retainer clip should be positioned at the level of the infant's armpits to ensure that the harness is snug and secure.

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A nurse in a clinic is collecting data from an adolescent who has type 1 diabetes mellitus.Which of the following findings is the priority for the nurse to report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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